Demand on primary and community services, the front door of the NHS and 90% of all activity, is at a critical point. Simon Stevens' Five Year Forward View tell us that the focus must be on integration, community based services and active, engaged citizens. The new primary care 'vanguard sites' have just been announced and everyone is thinking of locally focused new ways of joining services and resources up to meet the challenges we see each day.
It's a critical time for community nursing. Lord Willis has just announced his recommendations for the future of nurse training (the Shape of Caring Review) and, like many others, I am scouring them for traces of how future community nurses will be recruited and prepared. In my view, nurse training and nursing per se has to fundamentally change, to balance a pathogenic model with a salutogenic one.
A salutogenic approach to wellbeing
Salutogenesis is a word that few nurses currently know. 'Salus' meaning health and 'genesis' meaning origins. Many health professionals may misinterpret this as being about health improvement, which is a pathogenic or illness-avoiding concept.
To understand salutogenesis it is easiest to first reflect on our own lives. It is about having a reason for living, to have a life with purpose. Our existence, according to the founder of the concept, Aaron Antonovsky, is about a life that is comprehensible, manageable and meaningful. It is about feeling wanted and needed. It is about having friends that support us and a feeling of social inclusion.
Inequality, stress and health
And yet, in an increasingly disconnected and unequal society, our more vulnerable patients and residents are the ones that do not feel any of that. Take the family so poor that they can barely feed their children. The older resident who sees no-one for days on end. The workless, the bereaved, the desperate. A pathogenic model looks at the river of life in terms of upstream/downstream thinking. Give up smoking and prevent heart disease. A salutogenic model is about navigating the river of life and to do that you have to have some buoyancy aids – ways of coping. The biggest of these is having someone to turn to and believe in you.
There is little doubt that more unequal societies are less healthy. The Marmot Review 'Fair Society Healthy Lives' (2010) tell us this but the really detailed evidence comes from emeritus professor of epidemiology Richard Wilkinson in his seminal work 'The Spirit Level: Why Equality if Better for Everyone'(2009) where he shows, using statistical comparisons, that less equal societies endure 11 different health and social care problems, including physical and mental illness.
Richard Wilkinson gives a cogent explanation for why a rise in inequality breeds poor health: it increases the perceived threat to self-esteem and social status. This causes stress with the accompanying increase in cortisol that affects the circulatory system, causing illness. The most powerful sources of stress are low social status, stress in early life and lack of friends. If we have no friends our natural conclusion is that nobody likes us.
Social evaluative threat
After decades of caring for people we can create dependency and passivity, increasing demand. Many are beginning to feel services are transactional rather than relational. Patients are wary of consultations, box ticking and of projects that end, leaving them high and dry. They feel disengaged and alienated. Eventually when I gain the trust of the most disadvantaged, the words they use are about feeling judged by people like me. Professor Wilkinson calls it 'social evaluative threat'. They compare their status to mine and come up wanting. They tell me that they avoid stressors like visiting the health visitor for fear of being judged.
Self-help
Given that, in communities disadvantaged in multiple ways, the people most likely to suffer premature mortality are the ones most likely to avoid us, how do we meet their needs? In the NHS we talk endlessly about 'hard to reach' residents and about 'making every contact count'. In my view, when all you have is a hammer then everything looks like a nail. Grinding poverty gives people good reason to smoke and a continuous pathogenic narrative drives residents away from us.
Nurses need to enable self-help solutions and subsume our desire to rescue and cure. We must admit that in some instances, another resident with expertise in the same situation will help where we can't. I've blogged about this in the past, looking at both the research evidence and my personal experience of surviving two relatives with alcoholism. Self-help groups can be transformational. According to NESTA (2013), People Powered Health could save the NHS £4bn a year. More than this, it can offer true friendship.
Top 5 ways to tackle inequality using self-help
NESTA (2014) argues that 'people helping people' must be built into public service practice. For me that means nursing too. Here are my top 5 tips for enabling this:
1. If there is a self-help or voluntary group related to your area of clinical practice, meet them, create a relationship and find out how you can work alongside them. Make social prescribing part of your routine.
2. If you notice a number of people with the same un-addressed problem in the same neighbourhood, it's time to throw a party. Any excuse will do – a birthday, an anniversary, the launch of something. A local resident may be a more acceptable host than you, if there are issues of trust or shame.
3. The principle is 'make it fun and they will come'. An example of this is are the 'Leg Clubs' – tea, chat and wound care – helping people to get escape the social isolation a non-healing wound can bring and meet new friends. While having their leg ulcers seen to. The leg clubs are run by wound care nurses in community settings, not hospitals. People drop in an out and the emphasis is on social interaction.
4. Don't try to contrive anything, people in the same boat will naturally form bonds. They will self organize – maybe deciding to form a choir, start a 'man shed' or go out for fish and chips to the pub every first Tuesday in the month, like some carers for people with dementia do in my home town.
5. Connect, don't lead. It is a nurse's nature to help and solve problems. This creates dependency. Invite people to meet. If they need a room, offer one for free. If their 'knit and natter' group needs wool donations for knitting jackets for special care babies, introduce them to the wool shop owner. Make it theirs not yours, and they will support each other.
Self-help is non-judgemental. It is not a frivolous add on. It makes residents strong and confident and, most of all, it makes them well.
Heather Henry is an asset-base community development specialist and Queen's Nurse